This regular column is compiled by JCO Contributing Editor John W. Graham, DDS, MD. Selected participants are asked for brief replies to a series of questions on a single topic. Your suggestions for future Hot Seat topics or participants are welcome.
Similar articles from the archive:
- THE HOT SEAT Cone-Beam Computed Tomography August 2014
- THE HOT SEAT Temporary Anchorage Devices February 2014
- THE HOT SEAT Extractions August 2013
What percentage of your patients are treated using clear aligners?
William R. Womack, DDS
Peoria, AZ
30%.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
I have two Invisalign-only practices; a third office is about 75% Invisalign.
Anil J. Idiculla, DMD
Denver, CO
Currently one out of four patients in our practice is in aligner therapy.
Clark D. Colville, DDS, MS
Seguin, TX
30% of my patients are treated with Invisalign.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
In 2015, we will be at about 40% of our patients using clear aligners; this has grown from 12-15% just four years ago.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
60-65%. Clearly (pun intended), braces are in the minority for me. I attribute this not only to my increased confidence in what I can routinely do, but also to the marketing that has been done over the years.
Greg Nalchajian, DDS
Fresno, CA
27% overall, with 75% of adults and about 17% of teens wearing aligners.
Robert L. Boyd, DDS, MED
San Francisco, CA
I have used clear aligners (primarily Invisalign) at an increasing rate over the past 15 years and have been treating more than 85% of my patients with clear aligners during the past 10 years.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
70%.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
My practice is still 100% orthodontics! But 70% of my patients are using clear aligners as the main modality of treatment.
Commentary by Dr. Graham: Very punny, Jonathan. It’s clear where the trend is headed.
Do your patients seem to have realistic expectations regarding aligner therapy?
William R. Womack, DDS
Peoria, AZ
That depends on our first appointment orientation. It is my responsibility to make sure we understand how aligner treatment works and that we agree on expectations.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Patients’ expectations start off realistic. Sometimes they grow greedy and unrealistic by the end of treatment.
Anil J. Idiculla, DMD
Denver, CO
Yes, they do, the same as with fixed treatment. There are always outliers, though—and don’t we love them.
Clark D. Colville, DDS, MS
Seguin, TX
All my patients have the same expectations—a great result.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Yes; sometimes advertising triggers a call to the office, but they seem to know about aligners from online reviews. We spend a great deal of time educating our patients and let them choose what they think will work best for their lifestyle.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
They are easily managed by showing them similar cases treated with aligners. If I know a movement will be challenging, I explain that to them and then explain how we might get around that challenge (refinements, elastics, Propel, etc.).
Greg Nalchajian, DDS
Fresno, CA
Uh, that would be no. Do any patients ever have realistic expectations?
Robert L. Boyd, DDS, MED
San Francisco, CA
Not always, so it is necessary to first get them familiar with the goals that are possible and focus primarily on their responsibilities for compliance during treatment.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Yes, but not before explaining the treatment to them.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
Often in orthodontics, patient expectations are unrealistic. Our job is to educate ourselves first; then we can educate our patients properly.
Commentary by Dr. Graham: Nailed it, Greg!
What are the advantages of aligners over fixed appliances?
William R. Womack, DDS
Peoria, AZ
Some cases are treated better with aligners, especially when 60-70% of the occlusion is good. In these cases, fixed appliances will disrupt the “good”, due to an iatrogenic malocclusion created by imperfect bracket placement.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Better hygiene and esthetics, no dietary restrictions, no more white spots, and fewer or no emergencies.
Anil J. Idiculla, DMD
Denver, CO
Hygiene is not an issue; esthetics; front-loaded treatment planning; and patients come in asking for them.
Clark D. Colville, DDS, MS
Seguin, TX
No white-spot lesions, more comfortable, no diet restrictions, fewer office visits, no emergency visits, therapeutic diagnosis, greater efficiency.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Control of tooth movement, once a good diagnosis and treatment plan is devised; treatment of many types of open bite without the negative effects of fixed appliances on posterior teeth; new attachment protocols; deep-bite treatment.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
Greatly reduced chairtime, no emergency appointments, quicker appointments, happier patients, results as good as fixed appliances, and often faster treatment.
Greg Nalchajian, DDS
Fresno, CA
Removable, esthetic, more comfortable, more forgiving, and a magic bullet for open bites.
Robert L. Boyd, DDS, MED
San Francisco, CA
For adults, they are comfort and esthetics. But patients also experience other advantages like better hygiene and, for some patients who have had myofascial pain, relief in muscle soreness due to the double-splint effect of clear aligners.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
For periodontally involved cases, it’s the appliance of choice. It’s also better for long-distance patients.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
Great vertical control in high-angle and long-lower-face-height cases. Even when using Class II or III elastics, the vertical side effects are negated, and sagittal corrections are faster.
Commentary by Dr. Graham: Starting with the end in mind is always key. Love Anil's "front-loaded treatment planning".
What are the disadvantages of aligners over fixed appliances?
William R. Womack, DDS
Peoria, AZ
From years of trying to treat “everything”, we learned that some cases are beyond aligner treatment. The success in difficult cases is directly related to the skill and experience of the doctor.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Compliance, appliance loss; extrusive movement is challenging.
Anil J. Idiculla, DMD
Denver, CO
Compliance, high lab fees, and a different set of biomechanical thinking to achieve excellent results.
Clark D. Colville, DDS, MS
Seguin, TX
The outrageously high lab fees, compliance, inappropriateness for some malocclusions, and a steep learning curve.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Mixed-dentition treatment where one needs “partial braces” is just more effective with braces. Compliance has been an issue for both adolescents and adults, just as with fixed appliances and elastics or headgear.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
The expense, and I suppose sometimes compliance, but those are 2003 conversations—I’m way past that.
Greg Nalchajian, DDS
Fresno, CA
Removable, not great for deep bites, and reliant on patient cooperation, which is never a good idea.
Robert L. Boyd, DDS, MED
San Francisco, CA
The biggest problem with any removable appliance is compliance. If our patient does not give the required compliance, he or she will be asked to choose between making a new commitment, changing to fixed appliances, or stopping treatment.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Cooperation, as well as the need for several weeks of fixed appliances in premolar-extraction cases.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
The constant presence of the aligners over posterior surfaces makes posterior tooth eruption slow and difficult, especially in short-lower-face-height and overclosed cases.
Commentary by Dr. Graham: The “3 Cs”: Cost, Cooperation, Cost.
Beyond Class I crowded treatment, what malocclusions are ideally suited for clear aligners?
William R. Womack, DDS
Peoria, AZ
Upper extraction-only cases are predictable if no forward movement of the posterior teeth is required. I treated and published (in JCO) a four-bicuspid-extraction case and a surgical advancement case using only aligner treatment.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
All malocclusions can be treated with aligners, especially anterior open bite.
Anil J. Idiculla, DMD
Denver, CO
Open bites are a slam dunk. Also, many adult patients who want independent alignment of the jaws.
Clark D. Colville, DDS, MS
Seguin, TX
Anterior open-bite treatment and mild Class II treatment in growing patients.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
I utilize aligners for almost all malocclusions except palatally impacted maxillary canines. Mild Class II or III cases with elastics are now very predictable; open-bite cases with no severe skeletal problems are handily treated with aligners.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
We’re working on extraction protocols, so we can soon check that off the list of things once thought of as impossible with aligners. A skeletal discrepancy still needs to be handled properly but can be done in conjunction with aligners.
Greg Nalchajian, DDS
Fresno, CA
Open bites, arch development, Class II or III cases correctable by elastics, and pre-restorative treatment.
Robert L. Boyd, DDS, MED
San Francisco, CA
Numerous case reports have shown the treatment of Class II and III as well as open- and deep-bite malocclusions. Even reports of orthognathic surgery with no fixed appliances for the pre- or postsurgical orthodontics have recently appeared.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Just about everything, with the use of auxiliaries.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
Mild, moderate, and even severe open bites; mild-to-moderate crowding and spacing; half-cusp Class II and III discrepancies; mild or deep overbites in normal or long-lower-face-height patients; and orthodontic decompensation in surgical cases.
Commentary by Dr. Graham: Just like Grandma said at the pool, “Stay away from the deep end.”
Do you treat teen patients with clear aligners? If so, how has your experience been?
William R. Womack, DDS
Peoria, AZ
Teens need to be selected carefully. A frank discussion at the initial visit is critical; some teens tell me they would not keep up with removable appliances. We always state that braces may be needed to finish, and that is an additional cost.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Surprisingly, teen patients show more compliance than adults (and generally faster and better results).
Anil J. Idiculla, DMD
Denver, CO
Yes, I do, but as a younger practitioner I do not yet have the best cases for teenage aligner therapy (Phase II, Class I crowded, etc.). The ones we have treated have loved it and have done incredibly well.
Clark D. Colville, DDS, MS
Seguin, TX
About 50% of my aligner patients are adolescents. I see mostly great results with intermittent complete failures.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Absolutely. I give my patients a choice, explaining the advantages or disadvantages of each appliance system. They are great ambassadors, just like adults, for our use of aligners.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
Treating teens is a no-brainer—it’s un-teen-lievable! I was treating teens before there was a product and simply lying about the year of birth on the submission form.
Greg Nalchajian, DDS
Fresno, CA
In general, teens are better with aligners than adults. I’m not making this up—I have the data to prove it.
Robert L. Boyd, DDS, MED
San Francisco, CA
Among the first patients I treated with Invisalign in 1998 were teens. Several reports in the literature suggest that teeth move faster in growing patients than in adults.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Yes, excellent experience.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
I do treat many teens with clear aligners. My experience has been the same as with fixed braces: with good case selection, well-thought-out treatment plans, and good cooperation, results are excellent.
Commentary by Dr. Graham: Fan-teen-stick!
What are your thoughts regarding the new “at home/no office visit” aligner treatment options?
William R. Womack, DDS
Peoria, AZ
This is a dream—mad and misleading to the public. Participate at your own risk.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
A sad day for our specialty. Trusting patients to assess progress and modify their aligners at home?
Anil J. Idiculla, DMD
Denver, CO
This should be viewed as an eye-opening reality that patients undervalue what we can do for them. There might be a place for this in very limited treatment.
Clark D. Colville, DDS, MS
Seguin, TX
Sad, but fools and their money often go separate ways.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Absolutely. I give my patients a choice, explaining the advantages or disadvantages of each appliance system. They are great ambassadors, just like adults, for our use of aligners.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
Competition is good for everyone! I’m sure there is a market for it. Like most things in life, you get what you pay for; we will see what happens. Express or limited cases do not make up a large portion of my practice.
Greg Nalchajian, DDS
Fresno, CA
Are you kidding me? There’s a sucker born every minute.
Robert L. Boyd, DDS, MED
San Francisco, CA
Diagnosis, treatment planning, and treatment cannot ever be delegated to a “Popular Science” approach. I believe this product will fail, like so many other “solutions” devised by business to solve complex medical and dental problems.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
None. It sounds more scary than useful.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
Technology will always develop new ways of producing just “straight teeth”. What we as orthodontists do is different, and it is our responsibility to make that difference for our patients.
Commentary by Dr. Graham: Orthodontists screaming, “We’re different! We’re better!” is problematic in a day where patient perception is everything.
What has been the biggest “game changer” in aligner therapy for you in the last several years?
William R. Womack, DDS
Peoria, AZ
Enhancements to the ClinCheck software and the SmartTrack aligner material changed the game for everyone.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Improvement in the plastic material and three-dimensional software, as well as the attachment design.
Anil J. Idiculla, DMD
Denver, CO
The introduction of scanners for aligner therapy has been amazing: the speed of trays arriving from the manufacturer, outcome simulators, patient happiness, the fit of trays, and the ease of scheduling many of these scans on non-doctor days.
Clark D. Colville, DDS, MS
Seguin, TX
The ability to move the teeth in ClinCheck now puts the doctor in complete control of the aligner treatment.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
New materials, attachment designs, and treatment protocols have given me the confidence to routinely recommend aligner therapy. In 10 years, I believe close to 50% of all comprehensive orthodontics will be provided through aligner therapy.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
Early on, I realized that I am the doctor who should know how teeth respond to forces with a pushing plastic appliance. So I took responsibility for the ClinCheck. Some might say the beveled gingival attachment changed my life!
Greg Nalchajian, DDS
Fresno, CA
Better, more resilient aligner material and attachment protocols, as well as changing my “stinking thinking” (if you can’t beat them, join them).
Robert L. Boyd, DDS, MED
San Francisco, CA
The new, smaller attachment has “active” surfaces, developed by computer-based algorithms, which push the tooth in a specific direction. The newer materials have lower load values for improved comfort when aligners are changed.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Software improvements.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
The answer is in the question: “aligner therapy” itself is the game changer in 70% of my patient base. With constant and rapid development in the industry, the game keeps changing.
Commentary by Dr. Graham: The “3 Ss”: Software, Scanners, plaStic.
Given the higher cost of aligner therapy compared to fixed appliances, do you feel this treatment option has helped grow your practice?
William R. Womack, DDS
Peoria, AZ
Several years ago, we raised our fixed fee to match our aligner fee. It did not hurt our practice or the demand for aligner treatment.
Sam W. Daher, DDS, MSC
Vancouver, British Columbia
Absolutely. With shorter chairtime and a reduced number of visits, the cost is comparable.
Anil J. Idiculla, DMD
Denver, CO
Without a doubt, yes. It is a niche market here, and adults come in every week asking for aligners. The higher cost is definitely offset by the higher treatment fee. There is no need to discount aligner therapy by keeping it at the same price as your fixed treatment.
Clark D. Colville, DDS, MS
Seguin, TX
Absolutely, in every category: production, collection, overhead, and net profits. For me, it works.
Terry Carlyle, DDS, MSC, FRCD(C)
Edmonton, Alberta
Our clinical visits are eight weeks apart—they are efficient and short, and we do not have broken brackets or wires or other fixed-appliance headaches. I do not charge extra for the aligner therapy; our costs are virtually the same.
Jonathan Nicozisis, DMD, MS
Princeton, NJ
Yes, the lab fee is high; I think it is too expensive. I’m sure competition will drive that down in the future. I consider it part lab fee, part marketing fee, as no other company helps drive people into my practice—and this has for sure!
Greg Nalchajian, DDS
Fresno, CA
Without question. Follow the KISS rule to achieve profitability and good treatment outcomes. Don’t try to be a hero.
Robert L. Boyd, DDS, MED
San Francisco, CA
Several surveys have found lower doctor time with clear aligners compared to fixed appliances. Since doctor time is the most expensive single cost in orthodontic treatment, I have found I can charge the same fee but be more profitable overall.
Orhan C. Tuncay, DMD, FCPP
Philadelphia, PA
Of course—I charge higher fees.
Willy Dayan, DDS, DOrtho
Toronto, Ontario
Aligner therapy has helped me work smarter, not harder. It is not a “plug and play” system, but it is a great place to practice our profession.
Commentary by Dr. Graham: Agree with all—not to mention families I get because the parents sought aligners.